Every finding on record at Priority One Home Health Services, Inc.

On 8/21/24 through 8/27/24, an Emergency Preparedness survey was conducted by the Michigan Department of Licensing and Regulatory Affairs. At the survey, Priority One Home Health was found to be non-compliant at the standard level with the requirements for participation in Medicare at 42 CFR 484.102 Emergency Preparedness.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on record review and interview, the Agency failed to provide documentation that it had participated in the community based full-scale exercise required every two years, resulting in the potential for patients and staff not to be properly prepared in the event of an actual emergency. Findings include: On 8/26/24 at 2:40 PM., review of the Agency's Emergency Preparedness binder found no evidence the Agency had conducted the required full-scale community-based exercise every two years. No communication or effort was noted by the Agency in reaching out to the local incident command center to participate in the community-based exercise for the last 3 years. The above findings were reviewed with and acknowledged by the Administrator during an interview on 8/27/24 at 12:35 PM.

A Medicare recertification survey was conducted by the Michigan Department of Licensing and Regulatory Affairs from 8/21/24 through 8/27/24 at: Priority One Home Health 27196 Dequindre Rd. Warren, MI 48092 At the time of the survey, this Agency did not operate any branch offices. The services the Agency provides are: Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), Medical Social Work (MSW), and Home Health Aide (HHa). For this survey, 2 home visits (low census of 5) with record reviews, 3 active records without home visits, and 2 discharged records were reviewed, for a total of 7 records reviewed. At the conclusion of the survey, this Agency was found to be out of compliance with the conditions of participation for home health agencies at: 42 CFR Part 484.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the Agency failed to furnish Home Health Aide (HHa) services for 1 (P-1) of 1 home visits made deemed eligible for HHa services, out of a total sample of 7 records reviewed; failed to provide Occupational Therapy (OT), and HHa services as ordered in the physician's referral for home care in 2 (P-4, P-5) of 2 records reviewed with OT and HHa services ordered, and failed to inform the patient in advance of discharge from home care in 1 (P-6) of 2 discharge records, resulting in an unaddressed patient care needs and failure to exercise the right to appeal impending discharge from home care services. Findings include: P-1: The admit date to home care was 3/26/24, with diagnosis which included diabetes-type 2, peripheral vascular disease, and bilateral lower leg venous stasis ulcers. On 8/21/24 during a home visit with Skilled Nursing (SN), it was observed the patient and patient's husband were unable to walk safely out of their home. In addition, an interview with P-1 on 3/26/24 at 3 PM., revealed P-1 was paying out of pocket for aide services to provide personal care tasks that would be covered as a Medicare benefit. Subsequently, P-1 was queried if the home health agency offered aide services, would she accept. P-1 responded, "Yes, of course." This finding was discussed after the visit with the SN, who acknowledged the finding and stated she would follow-up with the physician to get an order for aide services to be started. In addition, review of the initial start of care (SOC) assessment (3/26/24) by skilled nursing documented under "Functional Status" that P-1 needed assistance or total care needs for grooming, dressing upper and lower body, bathing, and toilet transferring, all being examples that a home health aide would be of benefit for P-1. These findings were acknowledged by the Administrator (Staff A) during an interview on 8/21/24 at 4:40 PM. P-4: The start of care (SOC) date for home care services was 7/19/24, with diagnoses of diabetes type-2 with neuropathy, bilateral knee osteoarthritis, and falls-repeated. On 8/26/24, review of the physician referral for home care (7/17/24) ordered the following services to evaluate, treat, and provide patient care: Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), and Home Health Aide (HHA). Further record review found no documentation as to why the services of OT and HHA were not provided to the patient. No refusal by the patient/caregiver was noted, and no physician notification or change in order was evidenced in the medical record. This finding was acknowledged by the Administrator (Staff A) during an interview on 8/27/24 at 1:40 PM. P-5: The SOC date for home care services was 6/26/24, with diagnoses of chronic obstructive pulmonary disease (COPD), heart disease, and diabetes-type 2. On 8/26/24, review of the physician referral for home care "Face to Face" encounter ordered the following services on 5/15/24 to evaluate, treat, and provide patient care: Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), and Home Health Aide (HHA). Further record review found no documentation as to why the services of OT and HHA were not provided to the patient. No refusal by the patient/caregiver was noted, and no physician notification or change in order was evidenced in the medical record. P-6: The SOC date was 2/21/24 with diagnoses which included hypertension, peripheral artery disease, and right foot-2nd toe gangrene with amputation. Review of record noted P-6 was discharged from the Agency on 8/13/24. Further review found no evidence if CMS Form-10123-NOMNC (Notice of Medicare Non-Coverage) was filled out, explained, and signed by P-6 prior to her discharge. This finding was reviewed by the Administrator (Staff A) was he noted a copy would be found in the hard (paper) chart. During review of the hard chart, it was mutually discovered on 8/27/24 at 1:20 PM., that there was a filled out NOMNC form but was undated. Subsequently, there was no evidence to ensure if the patient was informed at least two days in advance of the impending discharge.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure its procedure to perform a comprehensive review was sufficient within accepted standards of professional practice in determining any potential adverse medication effects such as: side effects, drug interactions, and duplicate drug therapy in 1 (P-4) of 7 records reviewed, out of a total sample of 7 records reviewed, resulting in the potential for unrecognized adverse effects due to medications that could negatively affect all 5 current patients. Findings include: P-4: The start of care (SOC) date for home care services was 7/19/24, with diagnoses of diabetes type-2 with neuropathy, bilateral knee osteoarthritis, adjustment disorder with mixed anxiety/depression, and falls-repeated. On 8/26/24, review of the 14 medications listed on P-4's SOC medication reconciliation found 5 separate psychotropic medications along with 3 CNS (central nervous system) depressants. Further review noted the Agency's drug review found "No medication related issues identified." Subsequently, no physician communication was found in the medical record concerning the following findings. Two professional on-line pharmaceutical resources were choses to perform a side-by-side comparison of P-4's medication profile to verify there were no significant medication concerns. The first site, "Drugs.com" found 19 separate "Major" or serious interactions, 38 moderate level interactions, and 5 duplicate drug therapies. The second (Web MD interaction checker) found 9 separate serious interactions and 52 moderate level interactions. These findings were reviewed and acknowledged by the Administrator (Staff A) during an interview on 8/27/24 at 1:10 PM. Staff A stated this did not meet Agency expectations or its policy referenced below. Staff A also stated he would call the EMR (electron medical record) company to get an explanation why the software was failing to pick up even one of the serious drug interactions when the other two software applications both had numerous safety concerns. Further, the Agency failed to have policy or procedure language concerning drug review that ensured its EHR (electronic health record) followed compliance with current standards of practice and failed to produce evidence of performing an actual spot check of various drugs known to produce severe/major interactions and duplicative therapy. Agency Policy: "Medications" Section 4, page 16 (undated) stated, "Following the Start-of-Care assessment by the nurse or therapist, an individual patient medication profile is entered into a data base system to screen for any potential interactions. Any potential interactions and/or sensitivities identified are immediately brought to the attention of the physician."

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the plan of care (POC) provided the frequency and duration for all ordered disciplines in 2 (P-4, P-5) of 7 total records reviewed; failed to include all pertinent interventions with reportable parameters, safety precautions and objectively measurable goals specific to meet the needs of the patient in 4 (P-1, P-4, P-5, P-7) of 7 total records reviewed, resulting in patients not receiving care specific to their individual needs and the potential for poor patient outcomes. Findings include P-1: The admit date to home care was 3/26/24, with diagnosis which included diabetes-type 2 with neuropathy, peripheral vascular disease, and bilateral lower leg venous stasis ulcers. On 8/22/24, record review of P-1's POC noted no precautions or safety parameters for the primary diagnosis of diabetes. In addition, the POC failed to document any specified goals concerning any aspect of actual or potential patient care areas. The POC failed to include all the required elements to meet the individualized clinical and safety needs of the patient. The findings above were reviewed and acknowledged by the Administrator (Staff A) during an interview on 8/27/24 at 12:40 PM. P-4: The start of care (SOC) date for home care services was 7/19/24, with diagnoses of diabetes type-2 with neuropathy, bilateral knee osteoarthritis, adjustment disorder with mixed anxiety/depression, and falls-repeated. On 8/26/24, review of P-4's POC noted a failure to include the frequency or duration of home visits for 2 of 2 disciplines ordered, Skilled Nursing (SN) and Physical Therapy (PT). Further, the POC failed to include any goals which focused on an intended improvement that was measurable for all 5 listed goals. The findings above were reviewed and acknowledged by the Administrator (Staff A) during an interview on 8/27/24 at 1:10 PM. P-5: The SOC date for home care services was 6/26/24, with diagnoses of chronic obstructive pulmonary disease (COPD), heart disease, and diabetes-type 2. On 8/26/24, review of the POC revealed no frequency or duration of home visits for 1 of 2 disciplines ordered, Physical Therapy (PT). Further, the POC failed to include any goals which focused on an intended improvement that was measurable for all 12 listed goals. The findings above were reviewed and acknowledged by the Administrator (Staff A) during an interview on 8/27/24 at 1:25 PM. P-7: The patient was admitted to home care on 9/11/23 with diagnosis which included CHF (congestive heart failure), atrial fibrillation, and COPD (chronic obstructive pulmonary disease). Record review on 8/26/24, noted P-7's POC had no means to monitor for exacerbation (worsening) of the patient's primary diagnosis of CHF such as increase in weight or lower leg circumference measurements for signs/symptoms of fluid overload. In addition, the POC failed to include any goals which focused on an intended improvement that was measurable for all 15 listed goals. The findings above were reviewed and acknowledged by the Administrator (Staff A) during an interview on 8/27/24 at 2 PM.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on record review and interview, it was determined that the Agency failed to ensure the clinical record was complete, including assessments, notes and evaluations, for 2 (P-2, P-3) of 7 records reviewed, from a total sample of 7 records reviewed, resulting in an incomplete record, an incomplete depiction of the patient's health status, and the potential for unmet care needs. Findings include: P-2: The start of care (SOC) date was 8/16/24 with diagnoses which included hemiplegia (paralysis of right side after stroke), major depression, and hypertension. During record review on 8/22/24, it was noted that the Skilled Nursing (SN) visit note on 8/22/24 was blank. During survey entrance, the Administrator (Staff A) was queried when visit notes were to be completed and turned in. Staff A responded, "Within 24 hours after the visit." The following week on 8/27/24, the lone SN visit note was still blank. This finding was reviewed and acknowledged by Staff A during an interview on 8/27/24 at 12:45 PM and Staff A acknowledged again that the visit note did not meet Agency expectations of documentation being complete with submission within 24 hours of the visit. P-3: The SOC date was 8/15/24 with diagnoses which included hypertension and dementia. During record review on 8/22/24, it was noted that both SN and Physical Therapy performed home visits on 8/22/24, which were found to be blank. The following week on 8/27/24, both SN and PT notes from 8/22/24 were still blank. This finding was reviewed and acknowledged by Staff A during an interview on 8/27/24 at 12:55 PM and Staff A acknowledged again that the visit notes did not meet Agency expectations of documentation being turned in within 24 hours of the visit. The Agency had not provided the requested policy concerning the timeframe of completion and submission of visit note documentation at time of survey exit (8/27/24 at 2:15 PM).

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure a discharge summary was complete, provided the patient's health status at the time of discharge, progress toward goals, and forwarded to the physician within 5 days of discharge in 1 (P-6) of 2 closed records; and failed to ensure a transfer summary was sent to the physician/receiving facility within 2 business days of the patient's transfer for 2 (P-6, P-7) of 2 records in which the patient was transferred to an inpatient facility, out of a total sample of 7 records reviewed, resulting in the physician/receiving facility not having knowledge of the patient's health status at the time of transfer, the physician not having a clear picture of the patient's status at the time of discharge, the potential for unidentified continuing health care concerns and unmet care needs. Findings include: P-6: The SOC date was 2/21/24 with diagnoses which included hypertension, peripheral artery disease, and right foot-2nd toe gangrene with amputation. On 8/26/24, review of record noted P-6 was transferred to the hospital on 5/30/24 due to a fall with head trauma and uncontrolled bleeding as patient was on a blood thinner at the time. Further review found the transfer summary was embedded at the end of the transfer OASIS (Outcome and Assessment Information Set). However, the transfer summary contained no list of current medications P-6 was taking at the time of transfer. No progress towards goals, and no overall summary of care with response to interventions/treatments for all disciplines, Skilled Nursing (SN) and Physical Therapy (PT), was found within the transfer summary. In addition, the section at the end of the transfer summary titled "Notification of Transfer" was left blank regarding where and when the transfer summary was sent out. Subsequently, there was no evidence found in the medical record that a comprehensive transfer summary was sent out within two business days as required. Record review on 8/26/24 noted P-6 was discharged from the Agency and the discharge (DC) summary was embedded at the end of the DC OASIS. However, the DC summary contained no list of current medications P-6 was taking at the time of discharge. No progress towards goals, and no overall summary of care with response to interventions/treatments for all disciplines (SN and PT) was found within the DC summary. The findings above were reviewed and acknowledged by the Administrator (Staff A) during an interview on 8/27/24 at 1:40 PM. Staff A was queried if a DC summary was ever sent to the physician. Staff A looked up when the DC summary was sent out and replied, "August 23rd" which was outside of the requirement of within 5 business days of discharge. Review of the requested Agency policies concerning transfer and discharge of patients found no language with timelines or that either summary must be sent out to the receiving hospital (transfer) or physician (discharge). P-7: The patient was admitted to home care on 9/11/23 with diagnosis which included CHF (congestive heart failure), atrial fibrillation, and COPD (chronic obstructive pulmonary disease). Record review on 8/26/24, noted P-7 was transferred from the Agency on 10/3/23 due to "weakness, unsteady gait, fall x 2". Further review found the transfer summary was again at the end of the transfer OASIS and contained no list of current medications P-7 was taking at the time of transfer. No progress towards goals, and no overall summary of care with response to interventions/treatments for all disciplines (SN and PT) was found within the transfer summary. In addition, the section at the end of the transfer summary titled "Notification of Transfer" was left blank regarding where and when the transfer summary was sent out. Subsequently, there was no evidence found in the medical record that a comprehensive transfer summary was sent out within two business days as required. Further record review noted P-7 was discharged from the Agency on 10/9/23 due to death while in the hospital. Additional review on 8/26/24, noted the DC summary was embedded at the end of the "OASIS E - Discharge While Inpatient". The DC summary was void of any information concerning P-7, other than the date of death. No patient care findings were found in the DC summary involving P-7's care before, during or after P-7 was discharged from home care. No evidence was found in the medical record that the physician was sent a comprehensive DC summary within 5 business days as required. The findings above were reviewed and acknowledged by the Administrator (Staff A) during an interview on 8/27/24 at 2 PM.